Postpartum Hemorrhage in Emergency Medicine Clinical Presentation

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Postpartum Hemorrhage in Emergency

Medicine Clinical Presentation

Author: Maame Yaa A B Yiadom, MD, MPH; Chief Editor: Pamela L Dyne, MD more...

Updated: May 2, 2012

History

The clinical history should be taken as a primary survey (ABCs) of the patient. This should include collecting

an initial set of vital signs to guide the patients management, as the patient is positioned to begin the physical

examination. Keep in mind, that if the bleeding is very brisk, the patients mental status may wane. As a result,

this first set of questions should include queries about signs and symptoms that are most crucial in managing

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potential circulatory collapse, identifying the cause of postpartum hemorrhage (PPH), and selecting

appropriate therapies.[10]

Severity of bleeding

Is the placenta delivered?

What has been the duration of the third stage of labor?

How long has the bleeding been heavy?

Was initial postdelivery bleeding light, medium, or heavy?

Are symptoms of hypovolemia present such as dizziness/lightheadedness, changes in vision,

palpitations, fatigue, orthostasis, syncope or presyncope?

If evaluating a patient with delayed postpartum hemorrhage, what has been the bleeding pattern

since delivery?

Intervention guides

Is there a history of transfusion? What was the reason for transfusion? Is there a history of a

transfusion reaction?

Past medical history (particularly cardiovascular, pulmonary, or hematologic conditions)

Allergies

Predisposing factors and potential etiology

History of postpartum hemorrhageGravity, parity, length of most recent pregnancy, history of multiple gestations

Number of fetuses for the most recent pregnancy

Pregnancy complications (polyhydramnios, infection, vaginal bleeding, placental abnormalities)

If the placental was delivered, was it spontaneous, or was manual delivery required?

Current and past history of vaginal delivery versus cesarean delivery

If cesarean delivery, was it planned in advance, decided upon after a failed vaginal delivery

attempt, or performed emergently?

Other uterine surgeries such as myomectomy (transvaginal vs transabdominal), uterine septum

removal

Personal or family history of bleeding disorderMedications such as prescribed, over the counter, diet supplements, or vitamins (with particular

attention to anticoagulants, platelet inhibitors, uterine relaxants, and antihypertensives)

Vaginal penetration since delivery (tampons, finger, other foreign object, vaginal intercourse)

Signs or symptoms of infection such as uterine pain or tenderness, fever, tachycardia, or foul

vaginal discharge

Information helpful for continued management

When and where was the delivery?

Who assisted the delivery?

Where and with whom was prenatal care?

Healthy infant(s) delivered (any complications or concerns before, during, or after delivery)?Past surgical history

Next Section: Physical

Physical

As mentioned earlier, patients with postpartum hemorrhage (PPH) should be managed like all emergency

department resuscitation situations, with the history and physical examination occurring simultaneously while

following acute life support algorithms.


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The physical examination should focus on determining the cause of the bleeding. The patient may not have the

typical hemodynamic changes of shock early in the course of the hemorrhage due to physiologic maternal

hypervolemia.

Important organ systems to assess include the pulmonary system (evidence of pulmonary edema), the

cardiovascular (heart murmur, tachycardia, strength of peripheral pulses), and neurological systems (mental

status changes from hypovolemia).The skin should also be checked for petechiae or oozing from skin

puncture sites, which could indicate a coagulopathy, or a mottled appearance, which can be indicative of

severe hypovolemia.

Looking for occult postpartum hemorrhagein the form of a pelvic, vaginal, uterine, or abdominal wall

hematoma, or intra-abdominal or perihepatic bleedingis always an important consideration when unstable

hemodynamic findings are present without evidence of excessive vaginal blood loss.

Having a gynecologic examination bed is helpful but not necessary. The patient's pelvis can always be elevated

on an inverted bedpan (thick-side toward the patient's feet) cushioned with towels and a sheet for comfort.

Ensure that good lighting and suction are available before beginning.

Abdominal examination: Pain and tenderness (concerning for retained placenta tissue, rupture, or

endometritis), distension, boggy or grossly palpable uterus (at or above the umbilicus) is suggestive ofatony. Palpation of an overdistended bladder may indicate a barrier to adequate uterine contraction.

Perineal examination: A brisk bleed should be visible at the introitus; identify any perineal lacerations.

Speculum examination: Gently suction blood, clots, and tissue fragments as needed to maintain the view

of the vagina and cervix. Careful inspection of the cervix and vagina under good light may reveal the

presence and extent of lacerations.

Bimanual examination: Bimanual palpation of the uterus may reveal bogginess, atony, uterine

enlargement, or a large amount of accumulated blood. Palpation may also reveal hematomas in the

vagina or pelvis. Assess if the cervical os is open or closed.

Placental examination: Examine the placenta for missing portions, which suggest the possibility of

retained placental tissue.

Previous

Next Section: Physical

Causes

The 4Ts of postpartum hemorrhage (PPH) +1: tone, trauma, tissue, thrombosis, and traction. More than one

of these can cause postpartum hemorrhage in any given patient.

Uterine atony - "Tone": Atony is by far the most common cause of postpartum hemorrhage. Uterine

contraction is essential for appropriate hemostasis, and disruption of this process can lead to significant

bleeding. Uterine atony is the typical cause of postpartum hemorrhage that occurs in the first 4 hours

after delivery. Risk factors for atony include the following:

Overdistended uterus (eg, multiple gestation, fetal macrosomia, polyhydramnios)

Fatigued uterus (eg, augmented or prolonged labor, amnionitis, use of uterine tocolytics such as

magnesium or calcium channel blockers)

Obstructed uterus (eg, retained placenta or fetal parts, placenta accreta, or an overly distended

bladder)

Laceration or hematoma - "Trauma": Trauma to the uterus, cervix, and/or vagina is the second most

frequent cause of postpartum hemorrhage. Injury to these tissues during or after delivery can cause


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significant bleeding because of their increased vascularity during pregnancy. Vaginal trauma is most

common with surgical or assisted vaginal deliveries. It also occurs more frequently with deliveries that

involve a large fetus, manual exploration, instrumentation, a fetal hand presenting with the head, or

spontaneously from friction between mucosal tissue and the fetus during delivery. Cervical lacerations

are rarer now that forceps-assisted deliveries are less common. They are more likely to occur when

delivery assistance is provided before the cervix is fully dilated. Risk factors for trauma include the

following:

Delivery of a large infant

Any instrumentation or intrauterine manipulation (eg, forceps, vacuum, manual removal of

retained placental fragments)

Vaginal birth after cesarean section(VBAC)

Episiotomy

Retained placenta - "Tissue": Retained placental tissue is most likely to occur with a placenta that has an

accessory lobe, deliveries that are extremely preterm, or variants of placenta accreta. Retained or

adherent placental tissue prevents adequate contraction of the uterus allowing for increased blood loss.

Risk factors for retained products of conception include the following:

Prior uterine surgery or procedures

Premature delivery

Difficult or prolonged placental deliveryMultilobed placenta

Signs of placental accreta by antepartum ultrasonography or MRI

Clotting disorder - "Thrombosis": During the third stage of labor (after delivery of the fetus), hemostasis

is most dependent on contraction and retraction of the myometrium. During this period, coagulation

disorders are not often a contributing factor. However, hours to days after delivery, the deposition of

fibrin (within the vessels in the area where the placenta adhered to the uterine wall and/or at cesarean

delivery incision sites) plays a more prominent role. In this delayed period, coagulation abnormalities

can cause postpartum hemorrhage alone or contribute to bleeding from other causes, most notably

trauma. These abnormalities may be preexistent or acquired during pregnancy, delivery, or the

postpartum period. Potential causes include the following:Platelet dysfunction: Thrombocytopenia may be related to preexisting disease, such as idiopathic

thrombocytopenic purpura(ITP) or, less commonly, functional platelet abnormalities. Platelet

dysfunction can also be acquired secondary to HELLP syndrome (hemolysis, elevated liver

enzymes, and low platelet count).

Inherited coagulopathy: Preexisting abnormalities of the clotting system, as factor X deficiency or

familial hypofibrinogenemia

Use of anticoagulants: This is an iatrogenic coagulopathy from the use of heparin, enoxaparin,

aspirin, or postpartum warfarin.

Disseminated intravascular coagulation(DIC): This can occur, such as from sepsis,placental

abruption, amniotic fluid embolism, HELLP syndrome, or intrauterine fetal demise.Dilutional coagulopathy: Large blood loss, or large volume resuscitation with crystalloid and/or

packed red blood cells (PRBCs), can cause a dilutional coagulopathy and worsen hemorrhage

from other causes.

Physiologic factors: These factors may develop during the hemorrhage such as hypocalcemia,

hypothermia, and acidemia.

Uterine inversion - "Traction": The traditional teaching is that uterine inversion occurs with an atonic

uterus that has not separated well from the placenta as it is being delivered, or from excessive traction

on the umbilical cord while placental delivery is being assisted. Studies have yet to demonstrate the

typical mechanism for uterine inversion. However, clinical vigilance for inversion, secondary to these
http://emedicine.medscape.com/article/253068-overviewhttp://emedicine.medscape.com/article/252810-overviewhttp://emedicine.medscape.com/article/779097-overviewhttp://emedicine.medscape.com/article/779545-overviewhttp://emedicine.medscape.com/article/272187-overview


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potential causes, is generally practiced. Inversion prevents the myometrium from contracting and

retracting, and it is associated with life-threatening blood losses as well as profound hypotension from

vagal activation.

PreviousProceed to Differential Diagnoses

Contributor Information and Disclosures

Author

Maame Yaa A B Yiadom, MD, MPH Staff Physician, Department of Emergency Medicine, Cooper

University Hospital, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical

School

Maame Yaa A B Yiadom, MD, MPH is a member of the following medical societies: Alpha Omega

Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians,

American Medical Association, American Public Health Association,National Medical Association, and

Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Daniela Carusi, MSc, MD Instructor, Obstetrics and Gynecology and Reproductive Biology, Harvard

Medical School; Consulting Physician, Department of Obstetrics and Gynecology, Medical Director,

Department of General Ambulatory Gynecology, Brigham and Women's Hospital

Daniela Carusi, MSc, MD is a member of the following medical societies: American College of

Obstetricians and Gynecologists, Association of Reproductive Health Professionals, and Massachusetts

Medical Society


Specialty Editor Board

Assaad J Sayah, MD Chief, Department of Emergency Medicine, Cambridge Health Alliance

Assaad J Sayah, MD is a member of the following medical societies:National Association of EMS

Physicians


Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska MedicalCenter College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson

Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of

Emergency Medicine, American College of Emergency Physicians, and American Medical Association
http://www.ama-assn.org/http://www.acep.org/http://www.aaem.org/http://www.naemsp.org/http://www.massmed.org/AM/Template.cfm?Section=Homehttp://www.arhp.org/http://www.acog.org/http://www.saem.org/http://www.nmanet.org/http://www.apha.org/http://www.ama-assn.org/http://www.acep.org/http://www.aaem.org/http://www.alphaomegaalpha.org/http://emedicine.medscape.com/article/796785-differential


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John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel

Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard

Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical

Center

John D Halamka, MD, MS is a member of the following medical societies: American College of

Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society forAcademic Emergency Medicine


Chief Editor

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los

Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine,

Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency

Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine


Additional Contributors

Special thanks to Dr. Donnie Bell for his assistance with the "Imaging" section for this topic.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous

author, Michael P Wainscott, MD, to the development and writing of this article.
http://www.saem.org/http://www.acep.org/http://www.aaem.org/http://www.saem.org/http://www.pbk.org/http://www.amia.org/http://www.acep.org/


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3. USAID (United States Agency for International Development). Postpartum Hemorrhage

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http://www.pphprevention.org/briefs_newsletters.php. Accessed September 9, 2008.

4. PATH. Saving Mother's Lives: Initiative promotes proven strategy for preventing postpartum

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Postpartum Hemorrhage in Emergency Medicine Clinical Presentation